Delayed abdominal closure has gained acceptance in managing a variety of surgical conditions. Multiple techniques were devised to promote safe, uncomplicated, expeditious fascial closure. We retrospectively reviewed patient records between September 22, 2001 and June 30, 2004. Of the 20 patients with open abdomen, two patients died within 24 hours and one was transferred. The remaining 17 were managed using an algorithm including a combination of delayed primary closure (DPC), vacuum-assisted fascial closure (VAFC), Wittmann Patch (WP) (Star Surgical, Inc., Burlington, WI), and planned ventral hernia via absorbable mesh with split thickness skin grafting (PVH). The mean Simplified Acute Physiology Scores (SAPS II) was 31 (predicted mortality 73%). All patients initially underwent VAFC and re-exploration 12–48 hours later. Indications for continued VAFC included 1) gross contamination, 2) massive bowel edema, 3) continued bleeding at re-exploration. If these conditions were absent, DPC was attempted or a WP was employed until fascial closure. Twenty-eight day mortality was 5.9 per cent (1/17 patients). Enterocutaneous fistulae occurred in two patients (11.7%). Fascial closure was achieved in 6 patients (35.3%). Eleven patients were managed with PVH. Using an algorithm with a combination of several techniques, open abdomen can be managed with minimal morbidity and acceptable closure rates.
Deep venous thrombosis (DVT) and pulmonary embolism (PE) affect high-risk trauma patients (HRTP). Accurate incidence and clinical importance of DVT and PE in HRPT may be overstated. We performed a ten-year retrospective analysis of HRTP of the Pennsylvania Trauma Outcome Study. High-risk factors (HRF) included pelvic fracture (PFx), lower extremity fracture (LEFx), severe head injury (CHI) (AIS – head ≥3), and spinal cord injury. HRF alone or in combination, age, Injury Severity Score (ISS), and Glasgow Coma Score (GCS) were examined for association with DVT/PE. A total of 73,419 HRTP were included: 1377 (1.9%) had DVT, 365 (0.5%) had PE. The incidence of DVT in level I trauma centers was 2.2 per cent and was 1.5 per cent in level II centers. The lowest incidence of DVT was 1.3 per cent for isolated LEFx; highest was 5.4% for combined PFx, LEFx, and CHI. Variables associated with DVT included age, ISS, and GCS (all P < 0.001). In logistic regression analysis, only ISS was consistently predictive for DVT and PE. Though increased during the past decade, the overall incidence of DVT in HRTP remains below 3 per cent. Only the combination of multiple injuries or an ISS >30 result in DVT incidence of ≥5 per cent. We believe that current guidelines for screening for DVT may need to be reevaluated.
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